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Technical Nuances of Surgical Implantation of Intrathecal Pain Pumps Susan Garruto MSN,CRNP,RNFA Thomas Jefferson University Hospital Disclosure • I have no affiliations to disclose Objectives • Identify patients who would benefit from intrathecal drug delivery • Describe the technique used for catheter/pump implantation • Explain the troubleshooting aspects of catheter/pump implantation Applications for Intrathecal Pain Pumps Spasticity (baclofen) • Multiple sclerosis • Traumatic brain injury • Cerebral Palsy • Cord injury • Paraparasis • Stroke Chronic pain (morphine, prialt) • Nociceptive pain Upper Spasticity Patterns Lower Spasticity Patterns Spasticity Trial • • • • • • Single bolus injection (50 mcg) Check effect over 8 hours >8 hour- start with ½ dose <8 hour- start with 2X dose No effect- increase bolus for trial Baclofen (Lioresal)- concentration for direct delivery is much more effective than oral baclofen. Pain Pump Trial • Morphine • Single bolus- will indicate adverse effects • Indwelling catheter to increase morphine dose to gain starting point for dosage in permanent pump. Patient selection Diagnostic Work Up • MRI • CT • Plain X-rays • Labs, INR, PTT Pre-op • • • • Pump size: 40 cc vs. 20 cc Drug of choice: Lioresal, other Chlorahexadine shower & wipes Revision- always have representative interrogate before surgery. Pre-op • Confirm pump size/ drug amount • Confirm plan for admission-including rehabilitation unit • Often involves caregiver • Introduce representative Intra-op Operating Room • Pre-operative antibiotics • Patient positioned in full lateral decubitusmay have to be creative! • Gel pressure points • Prep and drape back and abdomen simultaneously. Intra-op Operating Room • Local anesthesia • Minimal incision- don’t let the incision sacrifice accuracy or angle of reach. Need room to secure catheter. • Para-spinal lumbar puncture (L2-3-4) to prevent shearing of the catheter • Brisk flow of CSF • C-arm fluoroscopy to check catheter placement Implantation • Catheter is placed intrathecally (usually L3 or L4) and tunneled subcutaneously to the pump. • Tip placement at the T10T11 level • Acute hospital length of stay is 3-5 days Posterior lumbar Anchoring the catheter • 2 pursestring sutures- with Touhy needle in place • 2 butterfly anchors- anchor butterfly to catheter, anchor butterfly to fascia • Need to have fascial tissue, not fat • Protect catheter at all times (new catheter is not as delicate) • Allow for strain relief loop Abdomen • • • • • • • • • Placement in RLQ or LLQ-patient preference Below the waistline 2.5 cm beneath the skin Sub-fascial –extremely thin patients Trim catheter- hand off excess to be measured Check for CSF flow after tunneling 2 sutures to anchor pump Catheter lies posterior to the pump Access pump to confirm CSF flow before closing incision. • Copious antibiotic irrigation, anterior & posterior Intra-op Operating Room • • • • • Interrogate system before closure Meticulous closure Antibiotic ointment Tegaderm dressing Abdominal binder to prevent migration of generator • Flat for 12 hours Post-op • • • • • Pain medications Antibiotics for 24 hours Bathing instructions Wound care instructions Watch for complications- lack of drug delivery, infection Thomas Jefferson University Philadelphia, PA – USA Short video